Management of neuropathic pain induced by surgery: Review of the literature by a group of experts specialized in pain management, anesthesia and surgery.

Chronic postsurgical neuropathic pain (CPSNP) is frequent. While prevalence varies considerably according to type of operation and means of evaluation, it can reach 37% following breast surgery. Identification of risk factors related to the procedure and to the patient and taking into account the development of new, minimally invasive surgical techniques is increasingly nerve-sparing and reduces the likelihood of injury. CPSNP diagnosis in daily practice is facilitated by simple and quickly usable tools such as the NP4 4-question test. Management is based on pharmacological (analgesics, antiepileptics, antidepressants, local anesthetics) and non-pharmacological (kinesitherapy, neurostimulation, psychotherapy) approaches. In light of the present review of the literature, the authors, who constitute an expert group specialized in pain management, anesthesia and surgery, express their support for topical treatments (lidocaine, capsaicin) in treatment of localized postsurgical neuropathic pain in adults.

Efficacy and safety of a T-type calcium channel blocker in patients with neuropathic pain: A proof-of-concept, randomized, double-blind and controlled trial.

BACKGROUND: T-type calcium channels have been shown to play an important role in the initiation and maintenance of neuropathic pain and represent a promising therapeutic target for new analgesic treatments. Ethosuximide (ETX), an anticonvulsant and a T-type channel blocker has shown analgesic effect in several chronic pain models but has not yet been evaluated in patients with neuropathic pain. METHODS: This proof-of-concept, multicentre, double-blind, controlled and randomized trial compared the efficacy and safety of ETX (given as add-on therapy) to an inactive control (IC) in 114 patients with non-diabetic peripheral neuropathic pain. After a 7-day run-in period, eligible patients aged over 18 years were randomly assigned (1:1) to ETX or IC for 6 weeks. The primary outcome was the difference between groups in the pain intensity (% of change from the baseline to end of treatment) assessed in the intention-to-treat population. This study is registered with EudraCT (2013-004801-26) and ClinicalTrials.gov (NCT02100046). RESULTS: The study was stopped during the interim analysis due to the high number of adverse events in the active treatment group. ETX failed to reduce total pain and showed a poor tolerance in comparison to IC. In the per-protocol analysis, ETX significantly reduced pain intensity by 15.6% (95% CI -25.8; -5.4) from baseline compared to IC (-7.8%, 95% CI -14.3; -1.3; p = 0.033), but this result must be interpreted with caution because of a small subgroup of patients. CONCLUSION: Ethosuximide did not reduce the severity of neuropathic pain and induces, at the doses used, many adverse events. SIGNIFICANCE: This article shows that ETX is not effective to treat neuropathic pain. Nevertheless, per-protocol analysis suggests a possible analgesic effect of ETX. Thus, our work adds significant knowledge to preclinical and clinical data on the benefits of T-type calcium channel inhibition for the treatment of neuropathic pain.

A Symptomatic Killian-Jamieson Diverticulum Detected by Ultrasonography.

Killian-Jamieson diverticulum (KJD) is a rare entity resulting from the mucosal herniation through a lateral area of weakness known as the Killian-Jamieson space below the cricopharyngeal muscle. Ultrasonographic diagnosis is exceptional. Moreover, symptoms are found in only eleven percent of patients. KJD in its symptomatic form must be correctly identified because its therapeutic management is in some points different of Zenker's diverticulum.

Computed Tomography and Magnetic Resonance Anatomy of the Normal Orbit and Eye of the Horse.

Traumatic and infectious diseases of the eye and orbit can occur in horses. For diagnosis and monitoring of such diseases, medical imaging is useful including computed tomography (CT) and magnetic resonance imaging (MRI). The aim of the current study was to describe CT and MRI anatomy of the equine orbit and ocular globe. The heads from four adult horses were scanned with a 6-slice Emotion 6 CT (Siemens, Erlangen), and a 3.0 Tesla Siemens Verio 6 MRI using T1 and T2-weighted sequences. To validate CT and MR reference images, these were compared with anatomical models and gross anatomical sections. The bony limits of the orbital cavity, the relationship of the orbit with sinuses and foramina of the skull were well identified by CT. MRI was useful to observe soft tissues and was able to identify adnexae of the ocular globe (eyelids, periorbital fat, extraocular muscles, lacrymal and tarsal glands). Although MRI was able to identify all components of the eye (including the posterior chamber), it could not differentiate sclera from choroid and retina. The only nerve identified was the optic nerve. Vessels were not seen in this series of cadaver heads. This study showed that CT and MRI are useful techniques to image the equine orbit and eye that can have clinical applications.

Management of somatic pain induced by treatment of head and neck cancer: Postoperative pain. Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL).

OBJECTIVE: To present the guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL) concerning the management of somatic pain induced by the treatment of head and neck cancer, and in particular the management of early and late post-surgical pain. METHODS: A multidisciplinary work group conducted a review of the scientific literature on the study topic. An editorial group subsequently read the resulting guidelines before validation. RESULTS: It is recommended to prevent onset of pain caused by malpositioning on the operating table, as well as pain related to postoperative care. During surgery, it is recommended to spare nerve and muscle structures as far as possible to limit painful sequelae. Management of early postoperative pain upon tumor resection and flap harvesting sites requires patient-controlled analgesia by morphine pump. Physical therapy is recommended after flap harvesting to minimize painful sequelae. CONCLUSION: Preventive and curative measures should be undertaken for appropriate management of post-surgical pain in the treatment of head and neck cancers.

Management of somatic pain induced by head and neck cancer treatment: pain following radiation therapy and chemotherapy. Guidelines of the French Otorhinolaryngology Head and Neck Surgery Society (SFORL).

OBJECTIVES: The authors present the section of the guidelines of the French Otorhinolaryngology Head and Neck Surgery Society (SFORL) for the management of somatic pain induced by head and neck cancer treatment concerning management of pain following radiation therapy and chemotherapy. METHODS: A multidisciplinary work group was entrusted with a literature review. Guidelines were drawn up based on the articles retrieved and the group members' experience. They were read over by an editorial group independent of the work group. A coordination meeting drew up the final version. Guidelines were graded A, B or C or as expert opinion in decreasing order of level of evidence. RESULTS: Particular care should be given to detection and early adapted treatment of pain induced by radiation therapy and/or chemotherapy, to improve quality of life in head and neck cancer patients.

Management of somatic pain induced by head-and-neck cancer treatment: definition and assessment. Guidelines of the French Oto-Rhino-Laryngology- Head and Neck Surgery Society (SFORL).

OBJECTIVES: The authors present the guidelines of the French Oto-Rhino-Laryngology- Head and Neck Surgery Society (Société Française d'Oto-rhino-Laryngologie et de Chirurgie de la Face et du Cou [SFORL]) for the management of somatic pain induced by head-and-neck cancer treatment, and in particular the instruments needed for the definition and initial assessment of the various types of pain. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence. RESULTS: The priority is to eliminate tumoral recurrence when pain reappears or changes following head-and-neck cancer treatment. Neuropathic pain screening instruments and pain assessment scales should be used to assess pain intensity and treatment efficacy. Functional rehabilitation sessions should be prescribed to reduce musculoskeletal pain and prevent ankylosis and postural disorder. Psychotherapy and mind-body therapy, when available, should be provided in case of chronic pain. In case of recalcitrant complex pain, referral should be made to a multidisciplinary pain structure. CONCLUSION: The management of somatic pain induced by head-and-neck cancer treatment above all requires identifying and assessing the intensity of the various types of pain involved, their functional impact and their emotional component.

Value of TENS for relief of chronic low back pain with or without radicular pain.

OBJECTIVES: To evaluate the efficacy of transcutaneous electrical neurostimulation (TENS) in patients with chronic low back pain (LBP). DESIGN: Prospective, randomized, multicentre, single-blind study. SETTING: Twenty-one French pain centres. PARTICIPANTS: Two hundred thirty-six consecutive adult patients consulting for chronic LBP, with or without radicular pain (mean age ± standard deviation: 53 ± 13 years; range: 28-86 years). INTERVENTION: Patients were randomly assigned to receive either active (n = 117) or sham (n = 119) TENS in four 1-h daily treatment sessions for 3 months. MAIN OUTCOME MEASURES: The primary outcome measured was improvement of functional status at 6 weeks (Roland-Morris Disability Questionnaire). Secondary outcome measures were improvement of functional status at 3 months, pain relief (weekly visual analogue scale assessments), positive functional repercussions of pain levels on quality of life, a diminution of the use of analgesic and anti-inflammatory medication, satisfaction with the overall treatment strategy and compliance. RESULTS: Functional status did not differ between the groups, whether at 6 weeks or 3 months (p = 0.351 at 6 weeks). A significant improvement between the first and last visual analogue scale assessments was observed in patients with either lumbar pain alone or lumbar and radicular pain treated with active TENS. Other outcome measures did not differ significantly between the two groups. CONCLUSION: There was no functional benefit of TENS in the treatment of patients with chronic LBP.

In-patient versus out-patient withdrawal programmes for medication overuse headache: a 2-year randomized trial.

BACKGROUND: Medication-overuse headache (MOH) management usually includes a medication withdrawal. The choice of withdrawal modalities remains a matter of debate. METHODS: We compared the efficacy of in-patient versus out-patient withdrawal programmes in 82 consecutive patients with MOH in an open-label prospective randomized trial. The main outcome measure was the reduction in number of headache days after 2 months and after 2 years. The responders were defined as patients who had reverted to episodic headaches and to an intake of acute treatments for headache less than 10 days per month. RESULTS: Seventy-one patients had a complete drug withdrawal (n = 36 in the out-patient group; n = 35 in the in-patient group). The reduction of headache frequency and subjective improvement did not differ between groups. The long-term responder rate was similar in the out- and in- patient groups (44% and 44%; p = 0.810). The only predictive factor of a bad outcome 2 years after withdrawal was an initial consumption of more than 150 units of acute treatments for headache per month (OR = 3.1; 95% confidence interval 1.1-9.3; p = 0.044). CONCLUSION: Given that we did not observe any difference in efficacy between the in- and out-patient withdrawals, we would recommend out-patient withdrawal in the first instance for patients with uncomplicated MOH.

[Otolaryngological cancer pain at the after-effects stage]. / Douleur des cancers ORL au stade des séquelles.

The standards of pharyngolaryngeal tumor treatment have changed over the years in an attempt to prevent laryngeal mutilation (partial surgery, endoscopic surgery, sequential radiotherapy, and chemotherapy). Pain induced by these treatments is frequent and varies from one treatment to another. Chemoradiotherapy induces less pain but often more severe pain, since 20% of these situations are not controlled by strong opioids. Pain from mucositis, although nonspecific to otolaryngic cancer, is more frequent and more severe, and prevention and treatment remain poorly defined. Pain from postradiotherapeutic necrosis (mandibula, laryngeal cartilage, etc.) is less frequent, delayed, and extremely severe. Cervical and shoulder pain is present in more than one-third of patients and stems from a number of mechanisms (myofascial and articulatory). It is secondary to radiotherapy or surgery (XIth cranial nerve lesions during curage or flap reconstruction). Finally, pain coexists with disturbances of basic functions (speech, swallowing, etc.) and the disability generated by treatments. Management of pain, suffering, and the psychosocial impact is essential.

Chronic cluster headache: a French clinical descriptive study.

BACKGROUND: Cluster headache (CH) is a relatively rare disease and episodic CH is more frequent than chronic CH. Few studies have described the characteristics of patients with chronic CH. METHODS: This was a descriptive study carried out by eight tertiary care specialist headache centres in France participating in the Observatory of Migraine and Headaches (OMH). From 2002 to 2005, OMH collected data from 2074 patients with CH, of whom 316 had chronic CH. From January to June 2005, 113 patients with chronic CH were interviewed using standardised questionnaires during a consultation. RESULTS: The male to female ratio was 4.65:1. Median age was 42 years. The majority of patients were smokers or former smokers (87%). 46% had primary chronic CH (chronic at onset) and 54% secondary chronic CH (evolving from episodic CH). Most patients had unilateral pain during attacks and 7% had sometimes bilateral pain during an attack. 48% reported a persisting painful state between attacks. Symptoms anteceding pain onset (mainly discomfort/diffuse pain, exhaustion, mood disorders) and auras were reported by 55% and 20% of patients, respectively. The functional impact of chronic CH was estimated as severe by 74% of patients, and 75.7% suffered from anxiety, as assessed by the Hospital Anxiety and Depression scale. There was no substantial difference in clinical presentation between primary and secondary CH. DISCUSSION: This study confirms the existence of auras and interictal signs and symptoms in patients with chronic CH, and male sex and smoking as CH risk factors. Primary and secondary chronic CH appear equally prevalent. Male sex does not appear to favour the shift from episodic to chronic CH.

[Primary and atypical facial pain: diagnosis and treatment]. / Algies faciales typiques et atypiques: du diagnostic au traitement.

PURPOSE: Facial pain is a frequently encountered symptom in general medical practice and encompass a wide group of facial problems. As correct diagnosis can usually be reached by history and physical examination for well defined typical clinical entities (trigeminal neuralgia, cluster headache) atypical facial pain may have many other potential causes (sinuses infection, temporomandibular joint syndrome, dental disorders...) so that diagnosis not appear an easy task. CURRENT KNOWLEDGE AND KEYPOINTS: Anatomical and physiological organization of facial nociceptive system, particularly trigeminal system, may explain the variability of facial pain. Although symptoms have been clearly identified mechanism of pain production remains controversial. Several factors (psychological, neurological, endocrine...) and mechanisms (neuropathic, vascular, myoarticular) may coexist and explain trouble in diagnosing and treating facial pain. FUTURE PROSPECTS AND PROJECTS: Better knowledge in identifying the cause of facial pain may lead to improve patient care and avoid patient frustration, medical nomadism, repetitive dental and otolaryngologic procedures, and finally non-compliance with treatment.

Investigation of parameters influencing the activation of a Pd/gamma-alumina catalyst during methane combustion.

The progressive activation of a Pd(2 wt %)/gamma-alumina catalyst under the reaction conditions of catalytic combustion of methane (CCM) was studied. The reasons of this activation were investigated by XPS, CO-chemisorption, and HR-TEM. The removal of carbon from the surface cannot explain the observed activation process. Sintering of the palladium particles was detected but this parameter alone does not fully explain the activation process of the catalyst. HR-TEM imaging evidences (i) that PdO is present both in the fresh and the active catalyst and (ii) that the PdO nanoparticles sinter and restructure (surface roughening) during the reaction. Development of preferential faces was not observed. It is suggested that this restructuring may be responsible for the activation process by facilitating the formation of an active oxygen layer on the PdO surface. CCM on Pd/gamma-Al(2)O(3) depends on the thermal history of the catalyst and is a structure-sensitive reaction.